IPHA Registration Form

Note :An asterisk ( * ) indicates a required field. Special characters not allowed.

Registration Form

Name *

Designation *

Organization *

Gender *

Male Female

Food Preference *

Vegetarian Non Vegetarian

Mailing Address *

City *

State *

Country *

Pin code / Zip *

Telephone Number(Office)

Telephone Number(Residential)

Mobile Number *

Email *

Category of delegate (please tick appropriate category) * - Click to know the fee details
Any Public Health Association Members ( Rs.2750 / - )	Student ( Rs.750 / - )	Other ( Rs.3500 / - )
Foreign Delegate ( 120 USD )

Name of accompanying persons (Spouse and Children only ): Rs.1750 /- Per Person. $50 /- Per Person (for Foreign Delegate)

Relationship

Pre-conference workshop( Rs.900 /- ) *

Yes


Payment Details :
A.) Registration
B.) Accompanying co-delegates fee
C.) Preconference workshop
Total
D.) Convenience Fee
Grand Total